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Inspection carried out on 28 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Pound House Surgery on 28 October 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal incidents were maximised.
  • Some risks to patients who used services were assessed and managed. However, not all reasonable steps were taken to assess and mitigate risks in relation to receiving and responding to patient safety alerts, Disclosure and Barring Checks, tracking and storing blank prescriptions, and maintenance and record keeping for the premises.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. However, not all staff had received training updates in a timely fashion.
  • Exception reporting rates were relatively high for heart failure and osteoporosis compared to CCG and national averages. The practice had taken a number of measures to try and reduce exception reporting rates.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw an area of outstanding practice:

  • The practice had developed a comprehensive strategy to further identify and improve outcomes for patients with dementia. The practice provided dementia screening, referrals to other services, and information about support organisations. The practice had conducted 335 dementia assessments since April 2016 and this resulted in 72 diagnoses of dementia. One GP and a member of reception staff were dementia champions and they had developed information packs for patients with dementia and their families. The practice had provided staff with training about dementia and identified and implemented measures to ensure the practice and environment were more dementia friendly. QOF figures for 2015 to 2016 showed that 94% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is higher than the CCG average of 85% and national average of 84%.

The areas where the provider must make improvement are:

  • Complete required actions identified in the fire risk assessment, such as undertaking and documenting an electrical installation check for both premises.
  • Ensure that appropriate building checks and maintenance are undertaken and documented for both premises to include gas safety checks.

The areas where the provider should make improvement are:

  • Ensure staff receive DBS checks appropriate to their role or that appropriate assessments are undertaken to determine whether these are required and to identify and mitigate risks.
  • Ensure that there are adequate systems for receiving and actioning all patient safety alerts.
  • Embed systems to ensure that the location of all blank prescriptions is comprehensively tracked and that all blank prescriptions are stored securely.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

CQC Insight

These reports bring together existing national data from a range of indicators that allow us to identify and monitor changes in the quality of care outside of our inspections. The data within the reports do not constitute a judgement on performance, but inform our inspection teams. Our judgements on quality and safety continue to come only after inspection and we will not make judgements on data alone.